THE JOURNAL FOR SPECIALISTS IN GROUP WORK

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Impact of Group Sandtray Therapy on the Self-

Esteem of Young Adolescent Girls

Yu-Pei Shen & Stephen A. Armstrong

To cite this article: Yu-Pei Shen & Stephen A. Armstrong (2008) Impact of Group Sandtray
Therapy on the Self-Esteem of Young Adolescent Girls, THE JOURNAL FOR SPECIALISTS IN
GROUP WORK, 33:2, 118-137, DOI: 10.1080/01933920801977397

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RESEARCH

Impact of Group Sandtray Therapy on the

Self-Esteem of Young Adolescent Girls
Yu-Pei Shen
Tzu Chi University
Stephen A. Armstrong
Texas A&M University-Commerce

The effectiveness of group sandtray therapy was examined using a pretest-posttest

control group design with young adolescent girls (n ¼ 37) identified as having low
self-esteem. A split-plot analysis of variance (SPANOVA) revealed statistically
significant differences between participants in the treatment and control groups
in self-esteem on five of the six subscales of the Self-Perception Profile for Children.
The implications of the findings are discussed.
Keywords: adolescent; group therapy; sandtray therapy; self-esteem

Researchers have identified adolescence as a chaotic and difficult period

of time characterized by increased vulnerability, tremendous changes
(Brendgen, Vitaro, & Doyle, 2002; Dies, 2000; LeCroy, 2004b), and
normative stressors (Hampel & Petermann, 2005). Adolescent girls
are particularly at high risk for developing mental health problems
(Hampel & Petermann; LeCroy). They seem to be more vulnerable than
boys to negative body image, body dissatisfaction, the likelihood of
developing an eating disorder (Burrows & Cooper, 2002), and interna-
lizing problems such as low self-esteem and depression (Bolognini,
Plancherel, & Bettschart, 1996; Martin & Gentry, 1997; Ohannessian,
Lerner, & Lerner, 1999). More adolescent girls than boys experience
low self-esteem (Birndorf, Ryan, & Auinger, 2005; Carlson, Uppal, &
Prosser, 2000; Israel & Ivanova, 2002).
Connor, Doerfler, and Toscano (2004) advocated gender-specific
prevention=intervention programs for a variety of issues that ado-
lescent girls may encounter. LeCroy (2004a, 2004b) recommended that
gender specific programs should be implemented in early adolescence

Yu-Pei Shen is an Assistant Professor in the Department of Child Development and

Family Studies at Tzu Chi University in Taiwan. Stephen A. Armstrong is an Assistant
Professor in the Department of Counseling at Texas A&M University-Commerce.
Correspondence concerning this article should be addressed to Stephen A. Armstrong,
Department of Counseling, Education North 202, P.O. Box 3011, Commerce,
TX-75429-3011. E-mail: steve_armstrong@tamu-commerce.edu.

THE JOURNAL FOR SPECIALISTS IN GROUP WORK, Vol. 33 No. 2, June 2008, 118–137
DOI: 10.1080/01933920801977397
# 2008 ASGW
118
 Shen, Armstrong / GROUP SANDTRAY THERAPY 119

prior to the onset of some of the serious problems that many adolescent
girls develop such as sexually transmitted diseases and illegal drug
use. In addition, the need for prevention programs that strengthen
self-esteem (Polce-Lynch, Myers, & Kilmartin, 1998), improve signifi-
cant relationships (Moran & DuBois, 2002) and assist the transitional
development of adolescent girls has been identified (Rice & Meyer,
1994). A warm, non-confrontational, flexible, creative and activity-
based approach can promote the establishment of a therapeutic
relationship with adolescents and positively impact their behaviors
(Leadbeater, Kuperminc, & Blatt, 1999; Pollock & Kymissis, 2001;
Russell & Phillips-Miller, 2002). Some researchers have recommended
school-based programs designed to address self-esteem issues in
adolescent girls (Block & Robins, 1993; Merwin & Ellis, 2004).
Even though many authors and researchers have recommended pro-
grams for the enhancement of self-esteem in early adolescent girls, iden-
tifying girls with low self-esteem may be challenging because many girls
this age conceal their problems and have difficulty trusting someone to
help them (LeCroy, 2004a, 2004b). Therefore, many girls who need help
may not seek it. Counselors who work in middle schools and are familiar
with the issues and needs of the young adolescent girls whom they serve
are in an advantageous position to identify girls with low self-esteem. If a
trusting relationship with these girls can be developed, they may be will-
ing to participate in programs that enhance self-esteem.
Self-esteem refers to ‘‘the extent to which one prizes, values,
approves, or likes oneself’’ (Blascovich & Tomaka, 1991, p. 115). High
self-esteem is considered to be a protective factor for mental health
problems (Birndorf et al., 2005; DuBois, Burk-Braxton, & Swenson,
2002) and for decreasing overall adjustment difficulties (DuBois
et al.). Research findings show that self-esteem typically declines in
girls from early to late adolescence (Block & Robins, 1993; Harter,
1999; LeCroy, 2004a, 2004b; Rosenberg, 1985). In addition to the typi-
cal declines of self-esteem in girls this age, early adolescent girls
from diverse populations may be more at risk for declining self-esteem.
Holcomb-McCoy and Moore-Thomas (2001) noted that societal images
and stereotypes have negatively affected the self-esteem of young
adolescent African American girls. Therefore, it appears that imple-
menting preventive and treatment programs for enhancing self-
esteem during the middle school years would be strategic.

Activity Group Therapy

Many girls from the age of 11–14 are still in the concrete oper-
ational stage of development (Meece, 1997). Children in this stage
often have difficulty expressing their feelings adequately through
120 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / June 2008

language. Draper, Ritter, and Willingham (2003) noted that children

in this age group could ‘‘benefit from a modality that is not completely
dependent on verbalization, that is, some experiences may be better
accessed through activity such as play, art, or some other form of
metaphoric communication’’ (p. 245). Slavson (1943) introduced an
activity group approach to therapy that used toys and games. Accord-
ing to Slavson, therapists need to convey acceptance and allow parti-
cipants to engage in self-directed activities. Activity group therapy
emphasizes the expression of feelings and fantasies through activities
and play rather than through verbal means (Lomonaco, Scheidlinger,
& Aronson, 2000). In addition to the therapist providing a sense of
freedom and acceptance, the interactions of children with each other
help them to improve communication and learn the rules of peer inter-
action, such as taking turns.
Bratton and Ferebee (1999) noted that expressive art activities
could be used therapeutically in activity group therapy. Expressive
art activities are experiential by nature and provide a unique means
of self-expression that works well with children and young adoles-
cents. Bratton and Ferebee also stated that structured expressive
art activities provide young adolescents with ‘‘opportunities to change
perceptions about self, others, and the world as they try out new roles
and solutions in the safety of the group’’ (p. 193). One expressive art
activity that Bratton and Ferebee used effectively in group work with
young adolescents was sandtray therapy.

Group Sandtray Therapy

Group sandtray therapy is an activity-based approach that has been
used successfully with children and young adolescents (Draper et al.,
2003; Flahive & Ray, 2007; Homeyer & Sweeney, 1998). Group sand-
tray therapy is an intervention in which ‘‘group members build small
worlds with miniature figures in individual trays of sand and share
about their worlds as they are willing’’ (Draper et al., p. 244). The
therapeutic effects of sandtray therapy are experienced through the
creation of sandtray scenes and the facilitation of a trained therapist
to unfold and process the intrapsychic and interpersonal issues of
group members (Homeyer & Sweeney).
Because young adolescent girls are developmentally interested in
peers, a group therapy approach to sandtray is preferable to individual
sandtray (Dies, 2000; Draper et al., 2003; Flahive & Ray, 2007). Group
sandtray therapy is physically active and provides children an indirect
means to self-disclose material that is painful or uncomfortable. With
sandtray, young adolescents can feel a sense of safety and empower-
ment (Homeyer, & Sweeney, 1998). Group sandtray therapy offers
 Shen, Armstrong / GROUP SANDTRAY THERAPY 121

young adolescent girls an opportunity to build significant relation-

ships with peers, which is an important developmental task for this
age (Moran & DuBois, 2002).
Even though a group approach that uses sandtray is developmen-
tally appropriate and has been recommended in the literature, there
is little quantitative research to support the effectiveness of this
approach, particularly with young adolescent girls. Draper et al.
(2003) noted that there was a need for research on group sandtray
therapy to determine its effectiveness. Others have stressed the
need to provide empirical research results in sandtray therapy and
the need to examine the effectiveness of sandtray therapy for different
populations and presenting issues (Flahive & Ray, 2007; Kestly, 2001).
There are no studies in the literature that examine the effective-
ness of sandtray therapy with diverse populations. However,
Cochran (1996) noted that person-centered therapies are beneficial
for treating culturally diverse populations of students. Constantine
(2001) stated that Hispanics tend to prefer interpersonal relation-
ships that are nurturing and loving rather than goal-oriented. Simi-
larly, Bailey and Bradbury-Bailey (2007) recommended that group
counselors who are not African American should respond to African
American adolescents in an accepting and non-judgmental manner.
Thus, a therapeutic approach that is warm, supportive and accepting
appears to be advantageous when conducting group work with
diverse populations.
In the current study, the group therapists used a humanistic theor-
etical approach to counseling. A humanistic approach with children is
grounded in child-centered theory, which is based on a belief that chil-
dren are capable of self-direction given an accepting and supportive
environment (Landreth, 2002). In addition, child-centered theory is
based on the premise that it is essential for child clients to experience
the core conditions in the therapy relationship in order for growth and
change to occur. Humanistic therapists believe that participants will
experience healing in a safe and contained environment that is full
of understanding, acceptance, freedom, and a sense of control (Kalff,
1980). Therefore, a dynamic interpersonal relationship between thera-
pist and clients is essential with a humanistic approach. Humanistic
therapists also believe that all people possess an inherent actualizing
tendency toward growth. In the current study, counselors were
instructed to accept all feelings in the group sessions while limiting
only those behaviors that were potentially destructive in nature
(Landreth, 2002). This approach allowed for cultural differences in
communication including ‘‘the emotive and affective quality of inter-
personal interactions’’ that are valued by many African Americans
(Sue & Sue, 2004, p. 15).
122 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / June 2008

Sue and Sue (2004) noted that culturally competent counselors are
in the process of becoming aware of their values, biases and precon-
ceived notions and how they may affect minority clients. Culturally
competent counselors attempt to understand the worldview of cultu-
rally different clients and practice culturally sensitive intervention
strategies (Sue & Sue). All of the group therapists in the current
study had multicultural coursework and previous clinical experience
with culturally diverse clients. Through their studies and clinical
experience, the therapists developed at least a basic level of cultural
competence, including an understanding of how cultural group
membership influences the formations of worldviews (Sue, 2001).
In supervision, the therapists were challenged to become aware of
how their biases might affect their relationships with culturally
diverse clients. The therapists also were challenged in supervision
to be congruent in their interactions with all clients. Congruence
and authenticity is valued highly by African American clients
(Sue & Sue).
The researchers limited the group to one grade because Zinck and
Littrell (2000) indicated that adolescent girls feel more comfortable
expressing themselves with girls of their age. Lomonaco et al. (2000)
noted that groups comprised of participants and therapists of the same
gender are developmentally beneficial particularly in interpersonal
learning. Draper et al. (2003) also recommended same-sex groups
with girls in this age group because the flirting that occurs ‘‘when
adolescent boys and girls are together can be a distraction to the group
work and may inhibit the openness and honest disclosure’’ that group
leaders strive to achieve (p. 251).
The purpose of the current study was to examine the effectiveness
of group sandtray therapy with seventh grade girls with low self-
esteem. Flahive and Ray (2007) recently conducted a group sandtray
therapy study with preadolescents with behavioral problems. The cur-
rent study extended and modified Flahive and Ray’s approach and
examined the effectiveness of this modality with young adolescent
girls. Thus, this research resembled Flahive and Ray’s study with a
different population, presenting issue, and instrumentation. Flahive
and Ray’s study focused on group sandtray therapy with preadoles-
cents experiencing behavioral problems. They suggested that their
research could be replicated, and that similar research could be
conducted on different populations either with group or individual
sandtray therapy. Flahive and Ray also recommended limiting group
size with children who participate in group sandtray therapy.
In the current study, the effectiveness of group sandtray therapy in
enhancing self-esteem in seventh grade adolescent girls was evaluated
by comparing scores of the treatment and control groups obtained on
 Shen, Armstrong / GROUP SANDTRAY THERAPY 123

the Self-Perception Profile for Children (SPPC, Harter, 1985). The

following question was addressed: Does group sandtray therapy
improve the self-esteem of a sample of seventh grade adolescent girls
as evidenced by scores on the SPPC? This research question was
tested across all six of the subscales in the SPPC. We hypothesized
that the posttest scores on the six subscales of the SPPC of the
treatment group would be statistically significantly higher than the
posttest scores of the control group.

METHOD

Research Design

This study utilized a quasi-experimental, pretest-posttest design

with a treatment group and a control group to determine the effects
of sandtray therapy on the self-esteem of young adolescent girls. The
treatment group received group sandtray therapy following the
pretest, whereas the control group did not receive therapy until
participants in the treatment group completed their posttest. Both
groups took the pretest and the posttest. The duration of group
sandtray therapy was 50 minutes per session, twice a week for nine
sessions. Researchers in previous studies recommended that group
sandtray therapy sessions last an hour (Flahive & Ray, 2007;
Hedges-Goettl & Tannenbaum, 2001); however, in the current study
therapists shortened the session time to accommodate the school
schedule. The frequency of group meetings (twice a week) has
promoted the development of trust in relationships among group
members (Tyndall-Lind & Landreth, 2000).

Participants
Participants were 40 seventh-grade adolescent female students
from three middle schools in three different cities in the southwest-
ern United States. Though 40 participants completed the pretest,
three participants were not included in the posttest results due to
attrition and unavailability for the posttest. Two of the original part-
icipants were not allowed to continue in the project because of ser-
ious discipline referrals to the principal. A third original
participant was screened out of the project because of a court case
involving sexual abuse. The researchers assigned the participants
to either the treatment or control group according to the equality
of the group means of the total scores on the pretest (M ¼ 97.75,
SD ¼ 17.51 for the control group; M ¼ 98.65, SD ¼ 17.13 for the
124 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / June 2008

treatment group). In other words, the researchers assigned parti-

cipants to the two groups (based on pretest scores) so that the group
means would be equal. The 37 remaining female participants
included 20 African-Americans (54%), 12 Whites (32%), and 5 His-
panic Americans (14%). The treatment group included 9 African
Americans, 6 Whites, and 3 Hispanic Americans whereas the control
group included 11 African Americans, 6 Whites and 2 Hispanic
Americans. Ages ranged from 11 to 13 years, with a median age of
12 years. Of the 37 participants, 26 (70%) were identified as aca-
demically at-risk students (students who failed the state mandated
criterion referenced test). Twenty-nine participants (78%) qualified
for reduced or free lunch, which is an indicator of lower socioeco-
nomic status.
School counselors identified seventh grade adolescent girls who pre-
sented with low self-esteem and referred them to the therapist
assigned to each school. Parents gave written permission for their chil-
dren to participate in the study. The therapist in each school screened
the referred students individually for approximately 15 minutes. After
screening, therapists included all girls who had been referred and
obtained written assent from all of them. Participants were informed
that the group would meet twice weekly for four and one half weeks
for a total of nine sessions.

Therapists
Three female therapists conducted group sandtray therapy in this
study. All of the therapists had training in the areas of sandtray ther-
apy, group therapy and play therapy. The therapists received
additional training in group sandtray therapy from the second author.
Two of the therapists were doctoral candidates in counseling and one
of these two was a licensed professional counselor. The third therapist
was a post-masters licensed professional counselor.
All of the therapists in the current study used a humanistic
approach to group sandtray therapy. In addition, all of the therapists
had previous experience counseling culturally diverse clients.

Instrumentation

Harter’s Self-Perception Profile for Children (SPPC; Harter, 1985),

a self-administered instrument, has been widely used in research to
measure feelings of competence in specific domains and overall self-
worth (Schumann et al., 1999). The instrument has five subscales that
assess perceived domain-specific competence (Scholastic Competence,
Social Acceptance, Athletic Competence, Physical Appearance, and
 Shen, Armstrong / GROUP SANDTRAY THERAPY 125

Behavioral Conduct) and a separate scale that assesses overall

self-worth (Global Self-worth). Each subscale on the SPPC consists of:

six items, half of which are reversed with respect to whether the first
part of the statement reflects high or low competency. To avoid socially
desirable responses, Harter devised a structured alternative format that
first asked children to decide which part of a two-part statement
describes them best and then asks them to decide if this is really true
or only sort of true (Schumann et al., 1999).

Reliability for the SPPC was established with an initial sample of

1543 children in grades 3 through 8, including 754 boys and 789 girls
(Harter, 1985). The sample was diverse socioeconomically, but did not
include representative proportions of children from different ethnic
groups. The SPPC had acceptable reliability with Cronbach’s alpha
ranging from .76 to .86 on the six subscales. Schumann et al. (1999)
studied the psychometric properties of the SPPC with a socioeconomi-
cally diverse sample of 2,267 Black and 2,167 White girls. Cronbach’s
alphas were higher for the White girls (.81 to .85) than the Black girls
(.71 to .76) on the six subscales.

Procedures

The procedures used in this research were modifications of those

used by Flahive and Ray (2007). Participants in the current study
were divided into small groups of four. All of the small groups were
heterogeneous by race. Given the school setting for the intervention
and recommendations in the empirical literature about the number
of sessions needed for group therapy to be effective, the researchers
decided that nine group sessions were sufficient (Muller, 2000; Young,
1994; Zinck & Littrell, 2000).
The treatment intervention was provided to five groups of four part-
icipants. Participants were provided with the opportunity to visually
and physically see and touch the sand, miniatures, and sandtray
(Draper et al., 2003). After the pretest was administered and parti-
cipants were assigned to condition, girls in the treatment group parti-
cipated in nine sessions of group sandtray therapy. Participants in the
control group received no treatment during this time period. After the
collection of posttest data was completed, participants in the control
group received the same group sandtray therapy as the treatment
group.

Session structure. Structure in group sessions can help reduce

anxiety in group members. Structuring group sessions also has been
acknowledged as developmentally appropriate for adolescents,
126 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / June 2008

because adolescents do not handle ambiguity well (Nichols-Goldstein,

2001). Therefore, a selected topic was structured into each session.
Topics were chosen based on the concerns and issues that most ado-
lescent girls experience in their development including physical
appearance (Keery, Boutelle, & van den Berg, 2005), relationships,
and social acceptance and competence (Hedges-Goettl & Tannenbaum,
2001; LeCroy, 2004b; Polce-Lynch et al., 1998). For example, in the
friends’ sandtray session, group members were instructed to build a
scene of themselves and their friends.

Sandtray room. Therapists set up a sandtray room in each middle

school. In each sandtray room, there were four 21-inch round plastic
sandtrays that were painted with ocean blue on the inside. Shelves
or tables were used to display miniatures. Each group had miniatures
in eight categories as recommended by Homeyer and Sweeney (1998)
including people, animals, buildings, vehicles, fences and signs, natu-
ral items, fantasy, and spiritual-mystical. Duplicates of the miniatures
were provided at each school in order to provide participants greater
choice in the selection of items.

Sandtray therapy. In the sandtray sessions, participants were

instructed on how to create or build their sandtray scenes (Homeyer
& Sweeney, 1998). Questions were encouraged if participants were
not clear about the instructions. As recommended by Flahive and
Ray (2007), therapists used a standard statement for participants to
help them build their scenes:

As you can see there are many and various miniatures on the shelves.
I would like you to take a look at them. I would like you to build a scene
of (the selected topic as described earlier) in your own sandtray by
using the sand and miniatures there. You may build your sandtray scene
in any way you like and use as many miniatures as you would like. When
you are working on building your scene, I will sit here quietly. Let me
know when you are finished.

Therapists allowed approximately 15 minutes for each group mem-

ber to create her scene in the tray, leaving about 35 minutes available
for processing the scenes. However, as the group sessions progressed,
participants took longer to build their scenes. During the building
phase, the therapist observed how each of the participants approached
the miniatures and built her sandtray scene.
After participants had created their scenes in the sandtrays, group lea-
ders invited group members to share their sandtray scenes. There were
no restrictions regarding the way they shared, nor were they forced to
share (Draper et al., 2003). The leader began the processing part of the
 Shen, Armstrong / GROUP SANDTRAY THERAPY 127

session with a statement such as, ‘‘What would you like to share about
your sandtray scene with us? There may be something there that you
do not want to share, and that is fine. You may share it in any way
you like.’’ Such statements encouraged participants to share at their
own pace. The leaders facilitated the processing of sandtray scenes by
asking questions such as the following. ‘‘What will you name your sand-
tray scene’’? ‘‘Can you tell me more about this (miniature’’? ‘‘What is this
(miniature) doing’’? Facilitators used reflective responses as individuals
talked about their scenes. The therapists also used group skills such as
linking to normalize responses and feelings and to promote universality
(Yalom & Leszcz, 2005). More facilitative and elaborative questions such
as the questions above may be referenced in Homeyer and Sweeney
(1998). The role of the therapist in sandtray therapy is to be a facilitator.
The therapist intervened or set limits if negative or harmful comments
were delivered in a session (Draper et al., 2003).

Data Analysis
Split-Plot Analysis of Variance (SPANOVA) was utilized in data
analyses to determine the effectiveness of group sandtray therapy
on self-esteem, and SPSS1 13 computer software was used to run
the analysis. SPANOVA is used to analyze data from mixed designs,
designs with at least one between-subjects factor and at least one
within-subjects factor (Shavelson, 1996).
With SPANOVA, all of the relevant factors in the analysis are ana-
lyzed together rather than separately, which comes closer to reflecting
the relationship of the factors being analyzed. SPANOVA also reduces
the risk of experiment-wise type I error and increases power by
partitioning error.

RESULTS

Pre- and post-test scores were obtained on all six of the subscales
in the SPPC: Scholastic Competence, Social Acceptance, Athletic
Competence, Physical Appearance, Behavioral Conduct and Global
Self-worth. The means and standard deviations (SD) for the scores
on the six subscales are presented in Table 1.
A SPANOVA was conducted on each subscale; the between-subjects
variable was treatment (waiting-list control group and sandtray
therapy group), and the within-subjects variable was time (pretest
and posttest). Model assumptions of split-plot analysis of variance
(SPANOVA), which include independence, normality, homogeneity
of variances, and homogeneity of covariances (Shavelson, 1996), were
128 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / June 2008

Table 1 Means and Standard Deviations for All Six Subscales in the SPPC

Pretest Posttest

Factor Mean SD Mean SD

Control group (n ¼ 19)

Scholastic Competence 15.26 4.21 14.11 3.74
Social Acceptance 16.63 5.33 14.42 4.66
Athletic Competence 16.89 4.40 17.05 3.92
Physical Appearance 14.53 5.33 14.00 4.80
Behavioral Conduct 17.95 4.42 15.32 3.74
Global Self-worth 16.68 4.78 16.11 3.63
Treatment group (n ¼ 18)
Scholastic Competence 14.56 4.87 17.56 3.93
Social Acceptance 19.28 3.59 20.72 2.67
Athletic Competence 16.00 3.69 18.00 3.14
Physical Appearance 15.89 5.37 18.33 3.82
Behavioral Conduct 16.94 3.65 18.28 2.76
Global Self-worth 17.00 4.35 20.06 2.86

Note. Higher scores reflect greater self-esteem.

tested and verified. Because numerous statistical tests were conducted

in this study, a conservative alpha level of .01 was used in order to
reduce the risk of experiment-wise type I error (Armstrong & Henson,
2005). Depending upon the existence of a significant interaction, a fol-
low-up analysis of either main effects or simple effects was conducted
to further analyze the results. Then effect sizes were calculated to
determine the practical significance of the results. Cohen’s d was the
effect size used in this study.
SPANOVA results showed that there was a statistically significant
interaction in the scores of the Scholastic Competence subscale
across treatment and time, F(1, 35) ¼ 13.758, p ¼ .001. The statisti-
cally significant interaction is shown in Figure 1. After a statistically
significant interaction is found, simple effects rather than main
effects are examined. A significant interaction indicates that the
results of main effects cannot be generalized. In the current study,
main effects would include differences between the treatment and
control groups, whereas simple effects would include differences
between pretest and posttest scores across the same independent
variable. In the treatment group, a statistically significant simple
effect was found between pretest and posttest on Scholastic Com-
petence, F(1, 17) ¼ 15.132, p ¼ .001, with a medium effect size,
Cohen’s d ¼ .68. There was no statistically significant simple effect
of the control group (waiting-list group) between pretest and posttest,
F(1, 18) ¼ 2.042, p ¼ .17.
 Shen, Armstrong / GROUP SANDTRAY THERAPY 129

Figure 1 Interaction of scholastic competence across treatment and time.

Results showed that there was a statistically significant interaction

in the scores of the Social Acceptance subscale across treatment and
time, F(1, 35) ¼ 13.607, p ¼ .001. The statistically significant interac-
tion is visually depicted in Figure 2. The results of the simple effects of
neither the treatment group nor the control group between pretest and
posttest were statistically significant.
There was no statistically significant interaction in the scores
of the Athletic Competence subscale across treatment and time,

Figure 2 Interaction of social acceptance across treatment and time.

130 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / June 2008

F(1, 35) ¼ 2.769, p ¼ .105. The main effect between the treatment and
control groups also was not statistically significant.
There was a statistically significant interaction in the scores
of the Physical Appearance subscale across treatment and time, F(1,
35) ¼ 7.53, p ¼ .01. A statistically significant simple effect of the
treatment group between pretest and posttest was identified, F(1,
17) ¼ 12.658, p ¼ .002, with a medium effect size, Cohen’s d ¼ .52,
but not in the control group across time, F(1, 18) ¼ .404, p ¼ .533, with
a negligible effect size, Cohen’s d ¼ .1.
A statistically significant interaction in the scores of the Behavioral
Conduct subscale across treatment and time was detected, F(1, 35) ¼
10.413, p ¼ .003. The results of the simple effect showed that there
was not a statistically significant difference in the treatment group
between pretest and posttest, F(1, 17) ¼ 2.693, p ¼ .119. There was
a statistically significant simple effect of the control group between
pretest and posttest, F(1, 18) ¼ 8.269, p ¼ .01, with a medium effect
size, Cohen’s d ¼ .64.
Finally, a statistically significant interaction was found in the
scores of the Global Self-worth across treatment and time, F(1, 35) ¼
8.039, p ¼ .008. The results of the simple effect showed that there
was a statistically significant difference in the treatment group
between pretest and posttest, F(1, 17) ¼ 14.807, p ¼ .001, with a large
effect size, Cohen’s d ¼ .83. No statistically significant difference was
found in the control group across time.
In summary, there were statistically significant interactions on five
of the six subscales of the SPPC. In addition, the effect sizes of the sim-
ple effects were notable, indicating practically significant differences
in the treatment group over time with no corresponding changes in
the control group.

DISCUSSION

Results of the current study indicated that group sandtray therapy

was effective in improving the self-esteem of young adolescent girls.
There were statistically significant interactions between participants
in the treatment group and the control group across time on five of
the six subscales of the SPPC: Scholastic Competence, Social Accept-
ance, Physical Appearance, Behavioral Conduct and Global Self-
worth. As Table 1 indicates, this contrast was the pattern for five
of the six subscales: the mean of the treatment group scores
increased and the mean of the control group scores decreased. In
addition, given that 25 of the 37 participants were not White, it
 Shen, Armstrong / GROUP SANDTRAY THERAPY 131

appears that group sandtray therapy is effective in improving

the self-esteem of young adolescent girls from different cultural
backgrounds.
Two of the areas of self-esteem that appear to mean the most to
young adolescent girls are perceptions of their social acceptance
among peers and their physical appearance. In the control group,
the mean of the scores on the Social Acceptance subscale declined
by over two points (13%) in five weeks. It appears girls in the con-
trol group were experiencing struggles in Social Acceptance while
girls in the treatment group were improving. An analysis of the sim-
ple effect sizes confirms this trend. The Cohen’s d effect size of the
control group declining (.44) is almost identical to the effect size of
the improvement in the treatment group (.46). Researchers have
identified the link between social support and self-esteem (Merwin
& Ellis, 2004; Moran & DuBois, 2002). It appears group sandtray
therapy may have prevented or protected girls in the treatment
group from experiencing the drop in this aspect of self-esteem that
is typical for girls in this age group (Block & Robins, 1993; LeCroy,
2004a).
Block and Robins (1993) noted that positive interpersonal relation-
ships are more strongly related to high self-esteem in adolescent
girls than boys. The group format in the current study provided girls
with an accepting group of peers and opportunities to interact with
girls and the female therapist in a safe and supportive environment.
In group sandtray therapy, messages that the participants were
cared for, respected, unique, and significant were delivered through
the nature of sandtray therapy, the dynamics and cohesion of the
group, and the therapeutic relationship between the girls and the
therapists.
Many young adolescent girls struggle with feelings of inadequacy
related to physical appearance. Holcomb-McCoy and Moore-Thomas
(2001) noted that African American adolescent females are especially
vulnerable to negative feelings related to physical appearance.
Burrows and Cooper (2002) noted that many girls are concerned about
their weight or shape. In the current study, girls in the treatment
group made statistically significant gains in their self-esteem in this
area. One of the advantages of same-gender groups with same-gender
therapists is the safety that can be experienced by girls when an issue
such as physical appearance is the topic of focus.
In the group session that focused on physical appearance, many
girls reported that they had negative feelings about their bodies,
but many of the participants created scenes that were beautiful.
These participants chose miniatures that symbolized beauty, such
as princess-like figures, butterflies, flowers, and shining and colorful
132 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / June 2008

miniatures. They stated that these beautiful miniatures symbolized

their personalities as well as their physical appearance. When the
participants chose to focus on the beauty of their personalities rather
than their physical attributes, it was different from what the thera-
pists expected, but the therapists accepted and reflected the subjec-
tive inner worlds of the participants. It appears that girls in the
treatment group were able to accept themselves better by combining
their views of their physical appearance with their views of their
inner beauty. In addition, group members conveyed acceptance of
each other’s appearance and personalities. This acceptance appeared
to help the girls place less emphasis on negative feelings they had
about their appearance and more emphasis on aspects of their
personalities they valued.
For example, one girl chose a mirror as a symbol in her sandtray to
represent how she felt about her physical appearance. As the therapist
focused on her feelings about her body image, other group members
encouraged her to focus on her attributes as a person. This feedback
appeared to help her accept herself more because the group accepted
her physical appearance and valued her strengths as a person. The
group’s acceptance appeared to help her improve her self-perception
and self-acceptance.
Tuckman and Jensen (1977) proposed five stages of group develop-
ment that include forming, storming, norming, performing and
adjourning. In the current study, the girls moved quickly through
the forming stage into the norming stage. As Tuckman and Jensen
noted, the norming phase begins early in the process and overlaps
with several other stages. ‘‘Norming includes all of the processes that
influence the establishment of rules and boundaries for the group’’
(Armstrong & Berg, 2005). By contrast, none of the groups had an
observable storming stage. This dynamic may have been influenced
by the style of the therapists and the developmental stage of the group
members. Although the physical appearance example above occurred
in only one group, the three therapists reported that all of the sand-
tray groups had a highly supportive and accepting climate. Given
the stages of group development, it was timely to cover the physical
appearance topic after the group had moved into the performing stage.
Without the deeper level of trust and acceptance that had been estab-
lished, group members would have probably been unwilling and
unable to self-disclose their feelings about their appearance. As the
group moved into the adjourning phase of the group, which was a
result of time limitations rather than a professional assessment of
readiness for closure, the therapists provided a structured positive
feedback exercise in the final session that facilitated an awareness
of each girl’s strengths.
 Shen, Armstrong / GROUP SANDTRAY THERAPY 133

Limitations and Suggestions for Future Research

In the research design, there was a control group but no comparison

group. Therefore, it is not clear whether group sandtray therapy was
more effective in improving the self-esteem of young adolescent girls
than other types of treatment would have been. In addition, the sam-
ple used in this study was relatively small. The study would have had
greater power if a larger sample had been used. Low power increases
the risk of type II error. Statistical significance is heavily influenced
by sample size (Armstrong & Henson, 2004). In the absence of fol-
low-up data, we are unable to determine whether the observed gains
were maintained over time. In addition, the SPPC is a self-report
instrument, and the validity of the results depends on whether the
participants are honestly answering questions. Even though the
therapists in the current study had a basic level of cultural compe-
tency, more extensive coursework, training and supervision in work-
ing with diverse populations may have resulted in larger gains in
self-esteem. Given these limitations, future research is needed to
further examine the effectiveness of group sandtray therapy with
diverse children and adolescents who have self-esteem issues.
Although self-esteem can be difficult to measure, it might be helpful
for parents and teachers’ perceptions of change in self-esteem to be
measured. Also, larger samples would provide more confidence in
the generalizability of the results.

Implications for Group Work

LeCroy (2004a) noted that little attention has been given to finding
effective preventive approaches with adolescents. The current study
provides a short-term, group intervention that enhanced the self-
esteem of young adolescent girls. Given that self-esteem is a protective
factor for mental health problems (Birndorf et al., 2005; DuBois et al.,
2002) and that low self-esteem is associated with adolescent girls who
have histories of suicidal ideation (Hull-Blanks, Kerr, & Robinson
Kurpius, 2004), it is critical to implement group programs that
enhance self-esteem in early adolescence in order to prevent poten-
tially serious mental health issues.
Group sandtray therapy is an economical, developmentally appro-
priate modality for young adolescents (Draper et al., 2003). The
current study used this modality to address self-esteem in young ado-
lescent girls at a time when their self-esteem is vulnerable to intra-
psychic and interpersonal factors that tend to diminish it (LeCroy,
2004a, 2004b). Developmentally appropriate and culturally responsive
134 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / June 2008

prevention programs and group interventions in schools are needed to

address important issues such as self-esteem.
Traditional talk approaches may be effective with certain issues
young adolescent girls face, but when dealing with issues such as body
image, physical appearance, and peer acceptance, indirect approaches
such as sandtray therapy that allow girls to express their perceptions
through metaphorical scenes may be less threatening. By increasing
the therapeutic distance for young adolescent girls, they may be able
to work through sensitive issues that are difficult to discuss openly.
Unfortunately, most university programs only provide training
in group work with adults rather than young adolescents (Steen,
Bauman, & Smith, 2007), and most university programs do not offer
training with expressive art approaches such as sandtray. In fact,
many university practica do not include any supervision for working
with young adolescents even if the trainee is specializing in counseling
this population. University programs need to provide training in
developmentally appropriate group counseling modalities that
have been shown to be effective with young adolescents. Training in
sandtray and other expressive art modalities would give adolescent
counselors additional developmentally appropriate tools that would
allow them to use indirect and nonverbal interventions with young
adolescent clients.

CONCLUSION

The findings of the current study support the effectiveness of group

sandtray therapy in improving self-esteem with young adolescent
girls. The findings indicate that girls can improve how they feel about
their physical appearance, peer relationships and academic achieve-
ment as a result of participating in this group intervention. Group
sandtray therapy appears to be an effective approach for addressing
self-esteem with young adolescent girls, which is a critical issue for
girls this age.

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